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Banz WJ, Davis J, Steinle JJ, Adler S, Oitker J, Winters TA, Higginbotham DA, Hou Y, Henry N, Peterson R, Meyers CY. (+)-Z-Bisdehydrodoisynolic Acid Ameliorates Obesity and the Metabolic Syndrome in Female ZDF Rats. ACTA ACUST UNITED AC 2012; 13:1915-24. [PMID: 16339123 DOI: 10.1038/oby.2005.236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The putative selective estrogen receptor modulator (+)-Z-bisdehydrodoisynolic acid (Z-BDDA) has been found to improve cardiovascular risk in rodents. The objective of this study was to investigate the effectiveness of (+)-Z-BDDA compared with the antidiabetic drug, rosiglitazone, in treating obesity and risk factors associated with the metabolic syndrome. RESEARCH METHODS AND PROCEDURES Female Zucker Diabetic Fatty rats were randomly assigned to three treatment groups for 29 weeks: control (C), 1.8 mg (+)-Z-BDDA/kg diet [control diet + (+)-Z-BDDA (CB)], or 100 mg rosiglitazone/kg diet [control diet + rosiglitazone (CR)]. At sacrifice, physiological, biochemical, and molecular parameters were examined. RESULTS CB animals gained less weight and exhibited a decrease in total body lipids (p < 0.05) as compared with C or CR rats. Body weight and total body lipids were the highest in CR rats (p < 0.05). Liver weights in CB and CR rats were lower (p < 0.05) than in C rats, whereas kidney weights were lower in CB (p < 0.05) than in C and CR animals. Fasting plasma glucose was lower (p < 0.05) in the CB and CR animals when compared with C animals. C rats exhibited the highest concentration of total plasma cholesterol, and CR-treated rats exhibited the lowest concentration. Plasma triglycerides followed the same pattern as plasma cholesterol. Histomorphometry of heart vasculature revealed that CB and CR treatments produced a significant shift from small to large venules and arterioles compared with C (p < 0.05). Liver expression profiles of peroxisome proliferator-activated receptor (PPAR) alpha, PPARgamma, and PPAR-regulated genes revealed encouraging CB-induced effects. DISCUSSION These results suggest that (+)-Z-BDDA may have applications in treating obesity and complications associated with the metabolic syndrome.
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Affiliation(s)
- William J Banz
- Department of Animal Science, Food, and Nutrition, Southern Illinois University, Carbondale, IL 62901-4317, USA.
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Abstract
OBJECTIVE There are significant individual differences in the extent to which mood and cognition change as a function of reproductive stage, menstrual phase, postpartum, and hormone therapy use. This review explores the extent to which variations or polymorphisms in the estrogen receptor alpha gene (ESR1) predict cognitive and mood outcomes. METHODS A literature search was conducted from 1995 to November 2009 through PubMed, Embase, and PsychINFO. Twenty-five manuscripts that summarize investigations of ESR1 in mental health were reviewed. RESULTS Among studies investigating ESR1 in relation to cognition, 11 of 14 case-control studies reported an association between ESR1 polymorphisms and risk for developing dementia. Three of four prospective cohort studies reported an association between ESR1 polymorphisms and significant cognitive decline. There are inconsistencies between case-control and cohort studies regarding whether specific ESR1 alleles increase or decrease the risk for cognitive dysfunction. The relationships between ESR1 and cognitive impairment tend to be specific to or driven by women and restricted to risk for Alzheimer disease rather than other dementia causes. Three of five studies examining ESR1 polymorphisms in relation to anxiety or depressive symptoms found significant associations. Significant associations have also been reported between ESR1 polymorphisms and childhood-onset mood disorder and premenstrual dysphoric disorder. CONCLUSIONS A strong relationship between ESR1 variants and cognitive outcomes is evident, and preliminary evidence suggests a role of the ESR1 gene in certain mood outcomes. Insights into the discordant results will come from future studies that include haplotype analyses, analyses within specific ethnic/racial populations, and sex-stratified analyses.
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Increase in the levels of chaperone proteins by exposure to β-estradiol, bisphenol A and 4-methoxyphenol in human cells transfected with estrogen receptor α cDNA. Toxicol In Vitro 2009; 23:728-35. [DOI: 10.1016/j.tiv.2009.02.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 12/08/2008] [Accepted: 02/22/2009] [Indexed: 11/21/2022]
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Ansari RA, Gandy J. Determining the transrepression activity of xenoestrogen on nuclear factor-kappa B in Cos-1 cells by estrogen receptor-alpha. Int J Toxicol 2007; 26:441-9. [PMID: 17963131 DOI: 10.1080/10915810701620317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Functional assays have been used to define the estrogenicity of xenoestrogens in cotransfection studies employing estrogen receptors in various cell lines. It is known that estrogen is able to affect transcription from other nuclear transcription factors, especially the nuclear factor-kappa B (NF-kappa B). The ability of selected xenoestrogens (methoxychlor [MXC], dieldrin, and o',p'-DDT) to transrepress the NF-kappa B-mediated transcription in Cos-1 cells was evaluated by cotransfection of human estrogen receptor-alpha (hERalpha). These xenoestrogens have been described as comparably potent xenoestrogens, whereas their relative binding activity (RBA) has been relegated to a lower order as compare to estrogen. The two NF-kappa B response element-containing SV40 promoter and -242/+54 cytomegalovirus (CMV)-expressing firefly luciferase (2 x NRE-PV-Luc and 2 x NRE-CMV-Luc, respectively) were transfected into Cos-1 cells with pRL-tk, expressing the renilla luciferase as internal control. The estrogen receptor was expressed from cytomegalovirus major immediate early promoter (CMV-MIEP) (CMV5-hERalpha). Treatment with 1 nM estrogen (E(2)) (26.2%), 5 nM E(2) (41.4%; p < .05), and xenoestrogens (methoxychlor [1 nM: 29.6%, p < .05; 10 nM: 22.6%), dieldrin [1 nM: 10.3%; 10 nM: 36.06%, p < .05], and o',p'-DDT [1 nM: 17.0%; 10 nM: 7.15%]) repressed transcription from 2 x NREX-PV-Luc. The antiestrogen, ICI 182,780, failed to antagonize the effects of xenoestrogens. The effects of xenoestrogens in transrepression of NF-kappa B by ERalpha were similar when 2 x NRE-CMV-Luc was employed as reporter. Statistically significant (p < .01) repression by 1 nM E(2) (69.2%), 5 nM E(2) (69.1%), 1 nM o',p'-DDT (51.4%), 1 nM dieldrin (47.3%), and 1 nM MXC (73.3%) were observed. The effect of these xenoestrogens without ERalpha cotransfection on 2 x NRE-PV-Luc- and 2 x NRE-CMV-Luc-mediated NF-kappa B transcription was not affected by the treatment alone. It is concluded that xenoestrogens, like estrogens, are capable of producing transrepression of NF-kappa B by hERalpha.
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Affiliation(s)
- R A Ansari
- Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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Ray S, Xu F, Li P, Sanchez NS, Wang H, Das SK. Increased level of cellular Bip critically determines estrogenic potency for a xenoestrogen kepone in the mouse uterus. Endocrinology 2007; 148:4774-85. [PMID: 17640991 PMCID: PMC4261232 DOI: 10.1210/en.2007-0537] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Xenoestrogen mimics estrogen-like activities primarily based on alterations of gene expression and interactions with estrogen receptor (ER)-alpha and -beta. However, the requirement for large concentrations to induce estrogenic phenotypes and low affinity for ERs has challenged the notion that prevailing xenoestrogens are significant health hazards. Here in this study, we show that under certain conditions, exposure of xenoestrogen could be potentially harmful in respect to enhanced uterine estrogenicity. Previously, we have demonstrated that estradiol-17beta up-regulates uterine Bip, a stress-related endoplasmic reticulum protein, via an ER-independent mechanism in mice. Moreover, this protein essentially involves in estradiol-17beta-mediated uterine growth response and ERalpha-dependent gene transcription. Here, we demonstrate that among three tested xenoestrogens, only kepone (>15-30 mg/kg) exerts sustained inductive response for uterine Bip expression. Interestingly, this kepone-induced Bip strongly correlates with ERalpha-dependent growth and gene expressional responses in the mouse uterus. Furthermore, these effects were strongly suppressed after knockdown of uterine Bip, via the adenovirus approach. Although kepone at 7.5 mg/kg was not effective, it was strongly stimulatory by the adenovirus-driven forced expression of uterine Bip. In contrast, the control green fluorescence protein virus was not effective in the aforementioned responses. Furthermore, the induction of uterine Bip by stress-related signals also revealed the onset of uterine growth in mice when exposed to a sublethal dose of kepone. Collectively, studies provide novel molecular evidence that Bip acts as a critical regulator to amplify estrogenic potency for a weak xenoestrogen kepone.
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Affiliation(s)
- Sanhita Ray
- Department of Pediatrics, Division of Reproductive and Developmental Biology, Vanderbilt University Medical Center, Nashville, TN 37232-2678, USA
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Adler M, Hou Y, Sandrock P, Meyers CY, Winters TA, Banz WJ, Adler S. Derivatives of Z-bisdehydrodoisynolic acid provide a new description of the binding-activity paradox and selective estrogen receptor modulator activity. Endocrinology 2006; 147:3952-60. [PMID: 16709609 DOI: 10.1210/en.2006-0316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Z-Bisdehydrodoisynolic acid [(+/-)-Z-BDDA], an estrogenic carboxylic acid, is highly active in vivo yet binds poorly to estrogen receptors (ERs). Studies of Z-BDDA and its enantiomers demonstrate therapeutic potential as selective ER modulators; however, the activity vs. binding paradox has remained. One possible explanation is that the carboxylic acid group of Z-BDDA may be modified in vivo to an ester or amide. Synthesis of these derivatives showed the relative binding affinity (RBA) of the methyl ester for ERalpha and ERbeta was increased approximately 14- and 20-fold, respectively, relative to the parent compound. Yet, this increased affinity did not result in increased reporter gene expression. In contrast, the amide showed an unexpected approximately 4-fold decrease in RBA to both ERs compared with the parent. The relationship among the RBAs of ester, acid, and amide is consistent with their predicted polarity, suggesting the carboxylic acid, and not the carboxylate of BDDA, binds to ERs. Studies at pH 6.5, 7.4, and 8.0 were consistent with a simple acid-base equilibrium model, with BDDA binding as the undissociated acid and with affinity equal to or exceeding that of estradiol, consistent with high in vivo potency. Furthermore, the alcohol BDD-OH also demonstrated high affinity and increased activity in gene expression assays. In addition to suggesting a resolution to the decades-old binding/activity paradox, these studies may provide a direction for definitive in vivo metabolic and pharmacokinetic studies and provide additional insight into the chemical and metabolic determinants of BBDA's unique tissue selectivity and selective ER modulator activities.
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Affiliation(s)
- Molly Adler
- Department of Physiology, Southern Illinois University, Illinois 62901, USA
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Abstract
Successful implantation is the result of reciprocal interactions between the implantation-competent blastocyst and receptive uterus. Although various cellular aspects and molecular pathways of this dialogue have been identified, a comprehensive understanding of the implantation process is still missing. The receptive state of the uterus, which lasts for a limited period, is defined as the time when the uterine environment is conducive to blastocyst acceptance and implantation. A better understanding of the molecular signals that regulate uterine receptivity and implantation competency of the blastocyst is of clinical relevance because unraveling the nature of these signals may lead to strategies to correct implantation failure and improve pregnancy rates. Gene expression studies and genetically engineered mouse models have provided valuable clues to the implantation process with respect to specific growth factors, cytokines, lipid mediators, adhesion molecules, and transcription factors. However, a staggering amount of information from microarray experiments is also being generated at a rapid pace. If properly annotated and explored, this information will expand our knowledge regarding yet-to-be-identified unique, complementary, and/or redundant molecular pathways in implantation. It is hoped that the forthcoming information will generate new ideas and concepts for a process that is essential for maintaining procreation and solving major reproductive health issues in women.
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Affiliation(s)
- S K Dey
- Department of Pediatrics, Vanderbilt University Medical Center, MCN D4100, Nashville, Tennessee 37232, USA.
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Pearce V, Nawaz Z, Xiao W, Wiedenfeld D, Boyle N, Smith D. 4-ethoxymethylphenol: a novel phytoestrogen that acts as an agonist for human estrogen receptors. J Steroid Biochem Mol Biol 2003; 84:431-9. [PMID: 12732288 DOI: 10.1016/s0960-0760(03)00064-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Estrogen is the natural agonist of the estrogen receptor (ER). However, certain plant-derived compounds or phytoestrogens have been identified that mimic estrogens and act as agonists and/or antagonists of ERs, depending on subtype and target tissue. Using thin layer chromatography (TLC), gas chromatography-mass spectrometry (GC-MS), and proton nuclear magnetic resonance (1H-NMR), we identified a simple phenol, 4-ethoxymethylphenol (4EM), found in Maclura pomifera that acts as an agonist of ER-alpha and ER-beta in HeLa and MCF-7 cells. To study the effect of 4EM on ER-alpha and ER-beta activity, we performed transient transfection assays and showed that 4EM activated ER-dependent gene transcription in a dose-dependent manner on both ER subtypes and this activity was inhibited by trans-4-hydroxytamoxifen (4HT). Further, 4EM-mediated transcription in ER-alpha, like estrogen, was enhanced in the presence of coactivators, steroid receptor coactivator-1 (SRC-1), CREB binding proteins (CBP), and E6-associated protein (E6-AP). We found that 4EM was specific for ER and did not activate transcription of the progesterone receptor.
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MESH Headings
- Binding, Competitive
- CREB-Binding Protein
- Chromatography, Thin Layer
- Dose-Response Relationship, Drug
- Estrogen Receptor alpha
- Estrogen Receptor beta
- Estrogens, Non-Steroidal/chemistry
- Estrogens, Non-Steroidal/pharmacology
- Gas Chromatography-Mass Spectrometry
- Genes, Reporter
- HeLa Cells
- Humans
- Isoflavones
- Ligases/metabolism
- Maclura/metabolism
- Magnetic Resonance Spectroscopy
- Models, Chemical
- Nuclear Proteins/metabolism
- Phenols/chemistry
- Phenols/pharmacology
- Phytoestrogens
- Plant Preparations
- Plasmids/metabolism
- Protein Binding
- Receptors, Estrogen/agonists
- Receptors, Progesterone/metabolism
- Recombinant Proteins/metabolism
- Tamoxifen/analogs & derivatives
- Tamoxifen/pharmacology
- Trans-Activators/metabolism
- Transcription, Genetic
- Transfection
- Tumor Cells, Cultured
- Ubiquitin-Protein Ligases
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Affiliation(s)
- Virginia Pearce
- Department of Cell Biology, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX 75390-8595, USA
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Meyers CY, Hou Y, Winters TA, Banz WJ, Adler S. Activities of a non-classical estrogen, Z-bis-dehydrodoisynolic acid, with ERalpha and ERbeta. J Steroid Biochem Mol Biol 2002; 82:33-44. [PMID: 12429137 DOI: 10.1016/s0960-0760(02)00150-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
(+/-)-Z-bis-Dehydrodoisynolic acid [(+/-)-Z-BDDA] is highly estrogenic in vivo, yet binds to estrogen receptor (ER) poorly. This paradox has raised the possibility of alternative ERs and/or molecular mechanisms. To address the possibility of high activities of Z-BDDA with ERbeta, we determined the activities of (+)-Z-BDDA and (-)-Z-BDDA, in cell culture and in vitro, comparing ERbeta to ERalpha. Transfectional analysis in Hela cells showed (-)-Z-BDDA is an agonist for gene activation with both ERalpha (EC(50) congruent with 0.3nM) and ERbeta (EC(50) congruent with 5nM), while little to no activity was observed with (+)-Z-BDDA. Similarly, in gene repression assays, (-)-Z-BDDA was active (EC(50) congruent with 0.2nM), but again minimal activity was exhibited by (+)-Z-BDDA. Binding to ERalpha and ERbeta in vitro used both competition and a direct binding assay. For ERalpha, the relative affinity of (-)-Z-BDDA was approximately 6% by competition and 1.7% by direct binding versus 17beta-estradiol (E2; 100%), while (+)-Z-BDDA also demonstrated binding, but with relative affinities of only 0.08% by competition and 0.3% by the direct assay. For ERbeta, the affinity of (-)-Z-BDDA was approximately 7% by competition and 1.5% by the direct assay relative to E2 (100%), while (+)-Z-BDDA had lower affinity, approximately 0.2% that of E2 by both assays. The paradox of potent in vivo activity but lower activity in receptor binding and in cell culture reporter gene assays, previously seen with ERalpha is now also associated with ERbeta. The failure of ERbeta to explain the activity-binding paradox indicates the need for additional in vivo metabolic and pharmacokinetic studies and continued consideration of alternative mechanisms.
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Affiliation(s)
- Cal Y Meyers
- Department of Chemistry and Biochemistry, Southern Illinois University, Carbondale 62901, USA
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Wilson T, March H, Banz WJ, Hou Y, Adler S, Meyers CY, Winters TA, Maher MA. Antioxidant effects of phyto-and synthetic-estrogens on cupric ion-induced oxidation of human low-density lipoproteins in vitro. Life Sci 2002; 70:2287-97. [PMID: 12005187 DOI: 10.1016/s0024-3205(02)01483-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Oxidation of low-density lipoproteins (LDL) promotes the formation of atherosclerotic plaques. Estrogenic compounds (EC) from foods and other natural products, and synthetic estrogenic compounds (SECs) may prevent heart disease by inhibiting LDL oxidation. In the present study, we tested the antioxidant capacities of two phytoestrogens, daidzein (DAI) and genistein (GEN), and four SECs, (+)- and (-)-Z-bisdehydrodoisynolic acid (ZBDDA), and (+)- and (-)-hydroxy-allenoic acid (HAA), on isolated human LDL subjected to oxidation by cupric sulfate. The effects of these estrogenic compounds on the kinetics of conjugated diene formation in LDL undergoing oxidation were evaluated with a lag-time assay with continuous monitoring of absorbance at 234 nm. Lag-time data revealed that (+)-HAA, (-)-HAA, (+)-ZBDDA, and (-)-ZBDDA had similarly stronger antioxidant activities than either GEN or DAI. We also found that (+)-HAA, (-)-HAA, (+)-ZBDDA, and (-)-ZBDDA strongly inhibited the formation of Cu+-induced thiobarbituric acid reactive substances (TBARS) in LDL, and that GEN and DAI were less effective for inhibiting LDL lipid peroxidation. Finally, electrophoretic evaluation suggested that (+)-HAA, (-)-HAA, (+)-ZBDDA, and (-)-ZBDDA protected the apolipoprotein B-100 of LDL against oxidation better than did GEN or DAI. In summary, the four SECs, (+)-HAA, (-)-HAA, (+)-ZBDDA, and (-)-ZBDDA, were more potent antioxidants than the phytoestrogens, DAI and GEN.
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Affiliation(s)
- Ted Wilson
- Department of Biology, University of Wisconsin-La Crosse, 54601, USA.
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Meyers CY, Hou Y, Robinson PD, Adler S, Banz WJ, Winters TA. Absolute structure determination of the highly biologically active bisdehydrodoisynolic acids. J Pharm Sci 2000; 89:513-8. [PMID: 10737912 DOI: 10.1002/(sici)1520-6017(200004)89:4<513::aid-jps8>3.0.co;2-e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In a project designed to relate the unexpected in vivo and in vitro properties exhibited by (+)- and (-)-bisdehydrodoisynolic acid with their absolute stereochemical structure, an X-ray crystal-structure analysis was undertaken of the highly estrogenic, poorly binding (-) enantiomer. (1) and (13)C NMR spectra are also reported for the first time. The crystal structure shows the cis juxtaposition of the carboxyl and ethyl groups, which are separated by a large torsion angle, and that only the carbon atom holding the carboxyl group is out of the plane in which the remainder of the fused three-ring moiety lies. The crystal structure, which unequivocally characterizes the (-) enantiomer as cis-13(S),14(R) and, implicitly, the (+) enantiomer as cis-13(R),14(S), will be useful in continued studies aimed at explaining the selective estrogen receptor modulation (SERM) of these enantiomers which, in some cases, produces significantly different end-organ effects compared to those of estradiol, in both males and females, affording the promise of a variety of therapeutic and pharmacologic applications.
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Affiliation(s)
- C Y Meyers
- Department of Chemistry and Biochemistry-4409, Southern Illinois University, Carbondale, Illinois 62901, USA.
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Srivastava S, Weitzmann MN, Cenci S, Ross FP, Adler S, Pacifici R. Estrogen decreases TNF gene expression by blocking JNK activity and the resulting production of c-Jun and JunD. J Clin Invest 1999; 104:503-13. [PMID: 10449442 PMCID: PMC481048 DOI: 10.1172/jci7094] [Citation(s) in RCA: 184] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Central to the bone-sparing effect of estrogen (E(2)) is its ability to block the monocytic production of the osteoclastogenic cytokine TNF-alpha (TNF). However, the mechanism by which E(2) downregulates TNF production is presently unknown. Transient transfection studies in HeLa cells, an E(2) receptor-negative line, suggest that E(2) inhibits TNF gene expression through an effect mediated by estrogen receptor beta (ERbeta). We also report that in RAW 264.7 cells, an E(2) receptor-positive murine monocytic line, E(2) downregulates cytokine-induced TNF gene expression by decreasing the activity of the Jun NH(2)-terminal kinase (JNK). The resulting diminished phosphorylation of c-Jun and JunD at their NH(2)-termini decreases the ability of these nuclear proteins to autostimulate the expression of the c-Jun and JunD genes, thus leading to lower production of c-Jun and JunD. The consequent decrease in the nuclear levels of c-Jun and JunD leads to diminished binding of c-Jun/c-Fos and JunD/c-Fos heterodimers to the AP-1 consensus sequence in the TNF promoter and, thus, to decreased transactivation of the TNF gene.
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Affiliation(s)
- S Srivastava
- Division of Bone and Mineral Diseases, Department of Pathology, Washington University School of Medicine and Barnes-Jewish Hospital, St. Louis, Missouri 63110, USA
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